Provider Demographics
NPI:1598377202
Name:STEWART, LEONARD JACK IV
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:JACK
Last Name:STEWART
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5801 ARGERIAN DR
Mailing Address - Street 2:STE 103
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33545-4140
Mailing Address - Country:US
Mailing Address - Phone:813-991-4991
Mailing Address - Fax:
Practice Address - Street 1:9000 WAUKEGAN RD STE 200
Practice Address - Street 2:
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053-2127
Practice Address - Country:US
Practice Address - Phone:847-375-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9113168363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant